Evaluation of prosthetic valve function and clinical utility.
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Evaluation of prosthetic valve function and clinical utility.

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Many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis selection in the individual patient and careful medical management and follow-up ...

Many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis selection in the individual patient and careful medical management and follow-up after implantation.

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  • mechanical valves can be quite difficult to assess with two-dimensional echocardiography. Although gross abnormalities can be detected, more subtle changes are often missed, especially with transthoracic imaging.
  • M-Mode image of a Bileaflet prosthetic valve -- leaflets form two parallel lines while open, disappearing when closed
  • measurementis often difficult because of the reverberations and artefactscausedbythe prosthesisstentorsewing ring
  • usually requires a position 0.5 to 1 cm below the sewing ring (toward the apex)
  • Schematic representation of the concept of the DVI. Velocity across the prosthesis is accelerated through the jet from the LVO tract. DVI is the ratio velocity in the LVO (Vlvo)to that of the jet (Vjet )
  • DVI is always less than unity, because velocity will always accelerate through the prosthesis. A DVI < 0.25 is highly suggestive of significant valve obstruction. Similar to EOA, DVI is not affected by high flow conditions through the valve, including AR, whereas blood velocity and gradient across the valve are.
  • Localized high gradient in a mitral bileaflet valve. A, Visualization of lateral (narrow arrow) and central (large arrow) jets on color Doppler image. B, C, Two Doppler envelopes are superimposed. The highest one, which presumably reflects the velocity within the central orifice, yields a value of peak gradient of 21 mm Hg, whereas the smallest one (lateral orifices) provides a gradient of 12 mm Hg.
  • Examples of bileaflet, single-leaflet, and caged-ball mechanical valves and their transesophageal echocardiographic char-acteristics taken in the mitral position in diastole(middle)and in systole(right). The arrows in diastole point to the occluder mechanism of the valve and in systole to the characteristic physiologic regurgitation observed with each valve. Videos 1 to 6 show the motion and color flow patterns seen with these valves Starr-Edwards valve, there is a typical small closing volume and usually little or no truetransvalvular regurgitation single tilting disc valves have both types of regurgitation, but the pattern may vary: the Bjork-Shiley valve has small jets located just inside the sewing ring, where the closed disc meets the housing, while the Medtronic Hall valve has these same jets plus a single large jet through a central hole in the disc The bileaflet valves typically have multiple jets located just inside the sewing ring, where the closed leaflets meet the housing, and centrally, where the closed bileaflets meet each other
  • The white or black arrows indicate the regurgitant jet(s). (A, B) Transoesophageal echocardiographic (TOE) views of normal physiological regurgitant jets (thin white arrows; A and B) and paravalvular regurgitant jets (thick white arrows; B) in mitral bileaflet mechanical valves
  • (G) TTE short axis view of a mild paravalvular regurgitation (one single jet occupying20% of circumference) in a transcatheter bioprosthetic aortic valve
  • Pannus formation on a St Jude Medical valve prosthesis in the aortic position as depicted by TEE. The mass is highly echogenic and corresponds to the pathology of the pannus at surgery
  • Prosthetic St Jude Medical valve thrombosis in the mitral position(arrow)obstructing and immobilizing one of the leaflets of the valve. After thrombolysis, leaflet mobility is restored, and the mean gradient (Gr) is significantly decreased.
  • De-gassing involves separation of the gas contained in the water (or blood). In the case of a tran-sient drop in pressure, the gas separates out be-fore redissolving in the water when normal pressure is re-established.
  • ie, the atrial side of a mitral pros-thesis or the ventricular side of an aortic pros-thesis Strands have been found to be more common in patients undergoing TEE for evalu-ation of the source of embolism than in patients examined for other reasons the thera-peutic implications of prosthetic valve-associat-ed strands remain unclear. Importantly, if strands consist of collagen, aggressive thera-peutic anticoagulation is not likely to com-pletely eliminate their embolic potential
  • Real-time three-dimensional transesophageal echocardiography of a normal mechanical mitral valve visualized from the left atrium with the leafletsin systole (A) and in diastole (B).
  • Real-time three-dimensional transesophageal echocardiography of a bioprosthetic mitral valve with vegetation on the atrial side of the leaflet as visualized from the left atrium (A) and left ventricle (B). In image B, the struts of the bioprosthetic valve are clearly visible. Black arrow points to the vegetation
  • Long-axis view of left ventricular outflow tract (LVOT) perpendicular to prosthetic valve leaflets in systolic phase shows residual opening angle (dashed lines) is 19°, which is still within normal limit (≤ 20°)

Evaluation of prosthetic valve function and clinical utility. Evaluation of prosthetic valve function and clinical utility. Presentation Transcript

  • DR. DURGAPAVAN,NIMS,HYDERABAD,INDIA Email:drdurgapavan@gmail.com
  • OUTLINEApproachClinical ExaminationCXR2DechoDopplerTEE3D echoCineFluoroCTCardiac catheterization EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • IntroductionThe introduction of valve replacement surgery in the early 1960s has dramatically improved the outcome of patients with valvular heart disease.Despite the improvements in prosthetic valve design and surgical procedures , valve replacement does not provide a definitive cure. Instead, native valve disease is traded for “prosthetic valve disease”. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • IntroductionAfter a valve is replaced, the prognosis for the patient is highly correlated with the function of the prosthetic valve like- hemodynamics, durability, thrombogenicity.Thus, early diagnosis of a prosthetic valve disorder is crucial for reducing morbidity and mortality. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • IntroductionSymptoms of prosthetic valve dysfunction may be non specific, making it difficult to differentiate the effects of prosthetic valve dysfunction from ventricular dysfunction, pulmonary hypertension, the pathology of the remaining native valves, no cardiac conditions.Although physical examination can alert clinicians to the presence of significant prosthetic valve dysfunction, diagnostic methods are often needed to assess the function of the prosthesis. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Types of prosthetic valvesProsthetic Valves are classified as tissue or mechanicalTissue: • Made of biologic tissue from an animal (bioprosthesis or heterograft) or human (homograft or autograft) sourceMechanical Made of non biologic material (pyrolitic carbon, polymeric silicone substances, or titanium)Blood flow characteristics, hemodynamics, durability, and thromboembolic tendency vary depending on the type and sizeEVALUATION OF PROSTHERIC VALVE characteristics of of the prosthesis and the patient FUNCTION-METHODS AND CLINICAL UTILITY
  • Types of Prosthetic Heart Valves Mechanical  Bileaflet (St Jude)(A)  Single tilting disc (Medtronic Hall)(B)  Caged-ball (Starr-Edwards) (C) Biologic  Stented  Porcine xenograft (Medtronic Mosaic) (D)  Pericardial xenograft (Carpentier- Edwards Magna) (E)  Stentless  Porcine xenograft (Medronic Freestyle) (F)  Pericardial xenograft  Homograft ( allograft)  Percutaneous  Expanded over a balloon (Edwards Sapiens) (G)  Self –expandable (Core Valve) (H) EVALUATION OF PROSTHERIC VALVE Circulation FUNCTION-METHODS AND CLINICAL UTILITY 2009, 119:1034-1048
  • Mechanical ValvesExtremely durable with overall survival rates of 94% at 10 yearsPrimary structural abnormalities are rareMost malfunctions are secondary to perivalvular leak and thrombosisChronic anticoagulation required in allWith adequate anticoagulation, rate of thrombosis is 0.6% to 1.8% per patient-year for bileaflet valves. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Biological ValvesStented bioprostheses Primary mechanical failure at 10 years is 15-20% Preferred in patients over age 70 Subject to progressive calcific degeneration & failure after 6-8 yearsStentless bioprostheses Absence of stent & sewing cuff allow implantation of larger valve for given annular size->greater EOA Uses the patient’s own aortic root as the stent, absorbing the stress induced during the cardiac cycle EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Biologic Valves ContinuedHomografts Harvested from cadaveric human hearts Advantages: resistance to infection, lack of need for anticoagulation, excellent hemodynamic profile (in smaller aortic root sizes) More difficult surgical procedure limits its useAutograft Ross Procedure EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Desired valvesMechanical valves - preferred in young patients who have a life expectancy of more than 10 to 15 years who require long-term anticoagulant therapy for other reasons (e.g., atrial fibrillation).Bioprosthetic valves Preferred in patients who are elderly Have a life expectancy of less than 10 to 15 years who cannot take long-term anticoagulant therapyA bileaflet-tilting-disk or homograft prosthesis is most suitable for a patient with a small valvular annulus in whom a prosthesis with the largest possible effective orifice area is desired.OF PROSTHERIC VALVE EVALUATION FUNCTION-METHODS AND CLINICAL UTILITY
  • Algorithm for choice of prostheticheart valve EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Approach to prosthetic valvefunction assesmentCLINICAL INFORMATION &CLINICAL EXAMINATIONIMAGING OF THE VALVES  CXR  2D echocardiography  TEE  3D echo  CineFluoro  CT  Cardiac catheterisation EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • HISTORYSubtle symptoms of cardiac failure or neurologic events can be clues to serious valve dysfunction. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • CLINICAL INFORMATIONClinical data including reason for the study and the patient’s symptomsType & size of replacement valve,date of surgeryPatient’s height, weight, and BSA should be recorded to assess whether prosthesis-patient mismatch (PPM) is presentBP & HR HR particularly important in mitral and tricuspid evaluations because the mean gradient is dependent on the diastolic filling period EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICALUTILITY
  • CXRchest x-ray are not performed on a routine basis in the absence of a specific indication.It can be helpful in identification of valve type if information about valve is not available. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • The location of the cardiac valves is best determined on the lateral radiograph.A line is drawn on the lateral radiograph from the carina to the cardiac apex.The pulmonic and aortic valves generally sit above this line and the tricuspid and mitral valves sit below this line.So me time s the ao rtic ro o t can be infe rio rly displace d which will shift the ao rtic valve be lo w this line . OF PROSTHERIC VALVE EVALUATION FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • For further localization prosthetic valves involves drawing a second line which is perpendicular to the patients upright position which bisects the cardiac silouette.The aortic valve projects in the upper quadrant, the mitral valve in the lower quadrant ,the tricuspid valve in the anterior quadrant and pulmonary valve in the superior portion of the posterior quadrant EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • On the frontal chest radiograph ( AP or PA ) - longitudinal line through the mid sternal body. draw a perpendicular line dividing the heart horizontally.The aortic valve - intersection of these two lines.The mitral valve - lower left quadrant (patient’s left).The tricuspid valve - lower right corner (the patients right) The pulmonic valve- upper left corner (the patients OF PROSTHERIC VALVE This method is less reproducible EVALUATION left).  FUNCTION-METHODS AND CLINICAL UTILITY
  •  Patients with cardiac valves often have chamber enlargement and cardiac rotation which can displace the positions of the valves as well as create difficulty when drawing lines through the cardiac silouette.These rules are meant as a guideline to better localize cardiac valves although they do not always work. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  •  Some bioprosthetic valves have components that determine the direction of flow which helps localize the valve prosthesis. If the direction of flow is from inferior to superior – likely aortic valve. superior to inferior- likely a mitral valve. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Radiologic Identification Starr-Edwards caged ball valve Radiopaque base ring Radiopaque cage Silastic ball impregnated with barium that is mildly radiopaque (but not in all models) EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Appearance of CarboMedics prosthesis on plain radiography. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Echo Imaging of Prosthetic Valves EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • TIMING OF ECHO CARDIOGRAPHICFOLLOW-UPIdeally, a baseline postoperative transthoracic echocardiography(TTE) study should be performed 3-12weeks after surgery, when the chest wound has healed, ventricular function has improved, and anaemia with its associated hyperdynamic state has resolved. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Bioprosthetic valves Annual echocardiography is recommended after the first 5years,Mechanical valves, routine annual echocardiography is not indicated in the absence of a change in clinical status. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • challenges in echocardiographyThe high reflectance leads toshadowingReverberations multiple echocardiographic windows must be used to fully interrogate the areas around prosthetic valves. transesophageal echocardiography is necessary to provide a thorough examination. For stented valves-ultrasound beam aligned parallel to flow to avoid the shadowing effects of the stents and sewing ring. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • The concept of pressure recovery EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • The primary goals of 2D echoValves should be imaged from multiple views, with attention to determine the specific type of prosthesis, confirm the opening and closing motion of the occluding mechanism, confirm stability of the sewing ring(abnormal rocking motion ) Presence of leaflet calcification or abnormal echo density attached to the sewing ring, occluder, leaflets, stents, or cage such as vegetations and thrombi EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Primary goals of 2D echo(cont) Calculate valve gradient Calculate effective orifice area Confirm normal blood flow patterns Detection of pathologic transvalvular and paravalvular regurgitation. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Starr-Edwards mitral prosthesis is shown. A: During systole, the poppet isseated within the sewing ring (arrows). B: During diastole, the poppet movesforward into the cageEVALUATION OF PROSTHERIC VALVE (arrows), allowing blood flow around the occluder. FUNCTION-METHODS AND CLINICAL UTILITY
  • St. Jude mitral prosthesis is demonstrated. A: During systole, the hemidisks areshown in the closed position (arrows). B: During diastole, the two disks arerecorded in the open position (arrows). EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • St. Jude aortic prosthesis is demonstrated. The sewing ring is indicatedby the arrows. The walls of the aortic root (Ao) often obscure themotion of the disks. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • M-ModeM-Mode echocardiography enables better evaluation of valve movements and corresponding time intervals and recognition of quick movements and fibrillations. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • For bioprostheses, evidence of leaflet degeneration can be recognized as leaflet thickening (cusps >3 mm in thickness)- earliest sign calcification (bright echoes of the cusps), tear (flail cusp).Prosthetic valve dehiscence is characterized by a rocking motion of the entire prosthesis.An annular abscess may be recognized as an echolucent, irregularly shaped area adjacent to the sewing ring of the prosthetic valve. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Assessment of Flow Characteristicsof Prosthetic ValvesNormal functioning mechanical prosthetic valves cause: some obstruction to blood flow closure backflow (necessary to close the valve) leakage backflow (after valve closure)The extent of normal obstruction and leakage of prosthetic valves depends on prosthetic valve design EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Valve type Flow CharacteristicsBall-in-cage prosthetic valve (Starr- much obstruction and little leakage.Edwards, Edwards Lifescience)Tilting disc prosthetic valve (Björk- less obstruction and more leakage.Shiley; Omniscience; Medtronic Hall)Bileaflet prosthetic valves (St. Jude Less obstruction and more leakage.Medical; Sorin Bicarbon; Carbomedics)Bioprostheses. little or no leakageHomografts, pulmonary autografts, and almost unobstructive to blood flow.unstented bioprosthetic valves(Medtronic Freestyle,Toronto, Ontario, Canada)Stented bioprostheses (leaflets obstructive to flow.suspended within a frame) EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Dopplar interogation EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • color flow imaging is often helpful to define the location and direction of the various flow patterns.pulsed and continuous wave Doppler imaging can be oriented to quantify flow velocity.Whenever velocity is higher than expected,consider the possibility of pressure recovery. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Challenges in doppler interogationvariability of flow through and around the different prosthesesSome prosthetic valves have more than one orifice and, consequently, a complex flow profile EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Challenges in doppler interogationBecause the signal-to-noise ratio for Doppler imaging is lower compared with two-dimensional echocardiographic imaging, the shadowing effect is even more pronounced and the ability to record a Doppler signal behind a prosthetic valve is very limitedMultiple views m be used to fullyinterrogate the regurgitant signal. ust EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Primary goals of dopplarinterogationASSESMENT OF OBSTRUCTION OF PROSTHETIC VALVEDETECTION AND QUANTIFICATION OF PROSTHETIC VALVE REGURGITATION EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Doppler Assessment of Obstruction of Prosthetic ValvesQuantitative parameters of prosthetic valve function Trans prosthetic flow velocity & pressure gradients, valve EOA, Doppler velocity index(DVI). EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Effective orifice area(EOA)Continuity equation EOA PrAV = (CSA LVO x VTI LVO) / VTI PrAV EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICALUTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICALUTILITY
  • EOA of mitral prostheses: Pressure half time may be useful if it is significantly delayed or shows significant lengthening from one follow-up visit to the other despite similar heart rates. continuity equation using the stroke volume measured in the LVOT. However, this method cannot be applied when there is more than mild concomitant mitral or aortic regurgitation.o better for bioprosthetic valves and single tilting disc mechanical valves.o underestimation of EOA in case bileaflet valves. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • PPM PPM occurs when the EOA of the prosthesis is too small in relation to the patients body size, resulting in abnormally high postoperative gradients. EOA indexed to the patient’ s body surface area. PPM AORTIC MITRAL Insignificant >0.85 cm2/m2. >1.20 cm²/m² moderate 0.65and0.85cm2/m2. 0.9-1.20 cm²/m² severe <0.65 cm2/m2. <0.90 cm²/m² EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Transprosthetic jet contour and acceleration time AT/ET > 0.4 AT and AT/ET, angle-independent parameters. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Doppler velocity indexDimensionless ratio of the proximal flow velocity in the LVOT to the flow velocity through the aortic prosthesisDVI=VLVOT/VPrAv• Time velocity time integrals may also be used in Place of peak velocitiesDVI= TVILVOT /TVIPrAv• Prosthetic mitral valves, the DVI is calculated byDVI=TVIPrMv/TVILVOT EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • DVI had a sensitivity, specificity, positive and negative predictive values,and accuracy of 59%, 100%, 100%, 88%, and 90%, respectively. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • IMPORTENCE DVI can be helpful to screen for valve dysfunction, particularly when the Crosssectional area of the LVO tract cannot be obtained Valve size is not known. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Transprosthetic velocity and gradient• The flow is eccentric - monoleaflet valves multi-windows examination three separate jets - bileaflet valves Localised high velocity may be recorded by continuous wave(CW) Doppler Interrogation through the smaller central orifice of the bileaflet mechanical prostheses overestimation of gradient EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Highvelocity or gradient alone is not proof of intrinsic prosthetic obstruction and may be secondary to prosthesis patient mismatch (PPM), high flow conditions, prosthetic valve regurgitation, or localised high central jet velocity in bileaflet mechanical valves. Increased heart rate. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Algorithm for interpreting abnormally high transprosthetic pressure gradients EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • DETECTION AND QUANTIFICATION OFPROSTHETIC VALVE REGURGITATION• Physiologic Regurgitation. closure backflow (necessary to close the valve) leakage backflow (after valve closure)- washing jetso short in durationo narrowo symmetricalo homogenousPathologic Prosthetic Regurgitation. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Homogeneous in color, with aliasing mostly confined to the base of the jet EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Pathologic Prosthetic RegurgitationPathologic regurgitation is either central  Pathologic jets tend to be high velocity, paravalvular. intense, broad, and highly aliased.Most pathologic central valvular regurgitation is seen with biologic valves, whereas paravalvular regurgita- tion is seen with either valve type and is frequently the site of regurgitation in mechanical valves. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Thrombus and PannusIn one surgical study of 112 obstructed mechanical valves, pannus formation was the underlying cause in 11 percent of valves, pannus formation in combination with thrombus was present in 12 percent, thrombus alone was the etiology in the remaining cases. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Distinction between thrombus andpannus Thrombus Large, mobile, less echo-dense, associated with spontaneous contrast, INR<2.5 Pannus Small firmly fixed (minimal mobility) to the valve apparatus highly echogenic, (fibrous composition) common in aortic position Para valve jet suggests pannus EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Abnormal echoesAbnormal echoes that may be found in patients with prosthetic valves are spontaneous echo contrast (SEC), microbubbles or cavitations, strands, sutures, vegetations, thrombus. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Spontaneous echo contrast (SEC)is defined as smoke- like echoes.SEC is caused by increased red cell aggregation that occurs in slow flow, for example, because of a low cardiac output, severe left atrial dilatation, atrial fibrillation, or pathologic obstruction of a mitral prosthesis.The prevalence of SEC is 7% to 53%. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Microbubbles are characterized by a discontinuous stream of rounded, strongly echogenic, fast moving transient echoesMicrobubbles occur at the inflow zone of the valve when flow velocity and pressure suddenly drop at the time of prosthetic valve closing, but may also be seen during valve opening.Microbubbles are probably due to carbon dioxide degassing. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Kaymaz et al75% of the normal bileaflet valves compared with 39% of the tilting-disk valves.In prosthetic valves with thrombotic obstruction, microbubbles were found in only 6% , whereas they reappeared after successful thrombolytic treatment with relief of valvular obstruction in 69%Microbubbles are not found in bioprosthetic valves. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Strands are thin, mildly echogenic, filamentous structures that are several mm long and move independently from the prosthesis.They are often visible intermittently during the car- diac cycle but recur at the same site.They are usually located at the inflow side of the prosthetic valve Strands are found in 6% to 45% of patients.Have a fibrinous or a collagenous composition. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Sutures are defined as linear, thick, bright, multiple, evenly spaced, usually immobile echoes seen at the periphery of the sewing ring of a prosthetic valve; They may be mobile when loose or unusually long. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • TEECareful alignment of the transducer is essential to fully display leaflet motion as comprehensively as possible.Multiplane imaging should be done at a minimum of every 30˚from 0–180˚. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • TEE evaluation immediately after valve replacement1. Verify that all leaflets or occluders move normally.2. Verify the absence of paravalvular regurgitation.3. Verify that there is no left ventricular outflow tract obstruction by struts or subvalvular apparatus.TEE diagnosis of prosthetic valve dysfunction1. Identification of prosthetic valve type.2. Detection and quantification of transvalvular or paravalvular regurgitation.3. Detection of annular dehiscence.4. Detection of vegetations consistent with endocarditis.5. Detection of thrombosis or pannus formation on the valve.6. Detection and quantification of valve stenosis.7. Detection of tissue degeneration or calcification. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • TEE Higher-resolution image than TTE Proximity of the oesophagus to the heart . Size of vegetation defined more precisely Absence of interference with lungs and ribs, a very detailed image can be obtained of the atrial side of the mitral valve prosthesis and especially the posterior part of the aortic prosthesis. Peri annular complications indicating a locally uncontrolled infection (abscesses, dehiscence, fistulas) detected earlier. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • limitation -inability to detect aortic prosthetic-valve obstruction or regurgitation, especially when a mitral prosthesis is present. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • CONSIDERATIONS IN TAVIThe echocardiographic evaluation of TAVI is , in most ways same as that for surgically implanted valvesBut 2 areas of chalenges areCaluculation of EOAQuantification of post TAVI AR EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • CONSIDERATIONS IN TAVILVOT diameter and velocity should be measured immediately proximal to the apical border of the stent. However, if the border of the stent sits low in the LVOT, which may occur more frequently with self- expandable prostheses (such as the CoreValve), it may be preferable to measure the LVOT diameter and velocity within the proximal portion of the stent at approximately 5-10 mm below the bioprosthetic valve leaflets. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • CONSIDERATIONS IN TAVIParavalvular regurgitation is more common following transcatheter aortic valve implantation versus standard valve replacement– 30-80% with 5- 14%being moderate or severe. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • CONSIDERATIONS IN TAVIDelayed migration and embolisation of the prosthesis have been reported following transcatheter valve implantation. The distance between the ventricular end of the prosthesis stent and the hinge point of the mitral valve measured in the parasternal long axis view can be used to monitor the position of the prosthesis during follow-up. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Considerations for IntraoperativePatientsTEE and epicardial and epiaortic ultrasoundTEE remains the most widely usedAmerican Society of Anesthesiologists has recommendedintraoperative TEE as a category II indication in patientsundergoing valve surgeryCurrent ACC & AHApractice guidelines recommendTEE as a class 1 indication for patients undergoing valvereplacement with stentless xenograft, homograft, orautograft valves. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Considerations for IntraoperativePatientsMultiple echocardiographic views are obtained to determine Appropriate movement of valve leaflets, Color flow Doppler should exclude the presence of paravalvular leaks• Immediate surgical attentionAny regurgitation that is graded moderate or severe,‘Stuck’’ mechanical valve leaflets,Valve dehiscence, Dysfunction of adjacent valves EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Stress Echocardiography in EvaluatingProsthetic Valve FunctionStress echocardiography should be considered in patients with exertional symptoms for which the diagnosis is not clear.Dobutamine and supine bicycle exercise are most commonly used.Treadmill exercise provides additional information about exercise capacity but is less frequently used because the recording of the valve hemodynamics is after completion of exercise, when the hemodynamics may rapidly return to baseline. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Stress Echocardiography(cont)Prosthetic Aortic ValvesGuide to significant obstruction would be similar to that for native valves, such as a rise in mean gradient >15 mm Hg with stress.Prosthetic Mitral ValvesObstruction or PPM is likely if the mean gradient rises > 18 mm Hg after exercise, even when the resting mean gradient is normal. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • RT-3D TEEExcellent spacial imagingEase of useEnables enface viewing(surgical view)adds to the available information provided by traditional imaging modalities. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Limitations of 3D echo poor visualization of anterior cardiac structures,poor temporal resolution,poor image quality in patients with arrhythmiastissue dropout EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • CinefluoroscopyStructural integrityMotion of the disc or poppetExcessive tilt ("rocking") of the base ring - partial dehiscence of the valveAortic valve prosthesis - RAO caudal - LAO cranial Mitral valve prosthesis - RAO cranial . EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Fluoroscopy of a normally functioning CarboMedicsbileaflet prosthesis in mitral position A=opening angle B=closing angle EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • St. Jude medical bileaflet valve Mildly radiopaque leaflets are best seen when viewed on end  Seen as radiopaque lines when the leaflets are fully open Base ring is not visualized on most models EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • MULTISLICE CTBecause of its high temporal and spatial resolution, MDCT has recently shown good potential in assessing prosthetic valve disorders.to evaluate the prosthetic valve motion in various planes, with a focus on leaflet motion and on the residual opening angle between leaflets. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • The residual openingangle, the angle between two leaflets when fully opened, is measured using the plane perpendicular to the two leaflets Normal limit (≤ 20°)• For a single-leaflet prosthetic valve, the maximal opening angle is recorded. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  •  Special attention is also paid to the relationship between the suture ring and the surrounding valve annulus for detecting thrombosis, paravalvular leak (suture loosening), pannus, pseudoaneurysm formation. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • MDCTEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • MDCTEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Thrombolysis impact EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • MDCT In IE MDCT clarify the extent of the damage to the valve and paravalvular region to provide the surgeon the information required for débridement and a redo of the valve replacement. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • Cardiac Catheterizationmeasure the transvalvular pressure gradient, from which the EOA can be calculated –Gorlin formula.can visualize and quantify valvular or paravalvular regurgitation by Contrast injection. In clinical practice, it is not commonly performed. Crossing a prosthetic valve with a catheter should not be attempted in mechanical valves because of limitations and possible complications. Tissue valves can be crossed with a catheter easily, but a degenerative, calcified bioprosthesis is friable, and leaflet rupture with acute severe regurgitation is possible. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • TAKE HOME Many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis selection in the individual patient and careful medical management and follow-up after implantation. EVALUATION OF PROSTHERIC VALVE FUNCTION-METHODS AND CLINICAL UTILITY
  • THANK YOUEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY